Healthcare Provider Details

I. General information

NPI: 1699228619
Provider Name (Legal Business Name): JACK MARK CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3160 GENEVA ST
LOS ANGELES CA
90020-1117
US

IV. Provider business mailing address

3160 GENEVA ST
LOS ANGELES CA
90020-1117
US

V. Phone/Fax

Practice location:
  • Phone: 213-368-3374
  • Fax:
Mailing address:
  • Phone: 213-368-3374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCPO01066
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO01066
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: